560 FW 7, Environmental Compliance and Environmental Management System Audits, Fish and Wildlife Service Manual, U.S. Fish and Wildlife Service

560 FW 7
Environmental Compliance and Environmental Management System Auditing

Supersedes 560 FW 7, FWM 376, 09/28/01

Date: November 2, 2009

Series: Pollution Control

Part 560: Pollution at FWS Facilities

Originating Office: Division of Engineering

7.1 What is the purpose of this chapter? This chapter provides guidance for conducting environmental compliance and Environmental Management System (EMS) conformance audits at Service facilities.

7.2 What are the objectives of the environmental auditing program? The objectives of our auditing program are to:

A. Establish Servicewide standards for audits to ensure compliance with applicable environmental laws and regulations, and

B. Assure the Director and program managers that we effectively address environmental problems that could:

(1) Impact our mission effectiveness,

(2) Jeopardize the health of our personnel or the general public,

(3) Significantly degrade the environment,

(4) Expose the Service to avoidable financial liabilities as a result of noncompliance,

(5) Erode public confidence in the Service and the Department of the Interior (Department), and

(6) Expose individuals to civil and criminal liability.

C. Determine if the audited facility’s EMS conforms to Executive Order 13423, and Departmental and Service policies.

7.3 What is an Environmental Management System (EMS)? An EMS is a planning tool that helps us achieve our environmental compliance obligations and environmental performance goals by properly managing our operations and activities. It is not a stand-alone plan; it’s designed to take into account existing responsibilities, programs, and activities. (See 515 DM 4 for more information about when an EMS is necessary and what it includes.)

7.4 What are the authorities for this chapter?

A. 515 DM 2, Environmental Auditing.

B. 515 DM 4, Environmental Management Systems.

C. Executive Order 13423, Strengthening Federal Environmental, Energy, and Transportation Management.

7.5 Who is responsible for administering the program? Table 7-1 shows the responsibilities for the program.

Table 7-1: Responsibilities for the Environmental Compliance Audit Program
These Service employees…	Are responsible for…
A. The Director	Approving policy for our environmental compliance and EMS conformance auditing program.
B. The Assistant Director – Business Management and Operations	The overall administration of the program.
C. Regional Directors	(1) Ensuring that their facilities are in compliance with environmental laws and regulations, and (2) Implementing the environmental compliance and EMS conformance auditing program in their Regions.
D. The Chief, Division of Engineering	Providing guidance, funding, and support for the establishment, management, quality control, and implementation of the program.
E. The Chief, Environmental Compliance Branch	(1) Establishing, managing, and overseeing quality control for the program; (2) Providing audit training for Regional personnel; (3) Managing a national database to track audit findings—the Environmental Facility Compliance Audit Tracking System (EFCATS); (4) Visiting one site in each Region at least every 3 years for a formal audit (see section 7.6B). This ensures the quality of the auditing program and consistency among the Regions; and (5) Recommending funding to the Chief, Division of Engineering for audits.
F. The Regional Environmental Compliance Coordinators (RECCs)	(1) Planning, conducting, and tracking audits and corrective actions within their Regions; (2) Providing technical assistance to field stations on environmental compliance and EMS issues; and (3) Identifying funding needs for environmental compliance issues.
G. Project Leaders/Facility Managers	(1) Ensuring required environmental compliance at their facility, (2) Ensuring EMS conformance if their facility has an EMS, (3) Correcting open deficient audit findings through proposed corrective actions and requesting funding to do so, and (4) Annually providing the RECC with an update of the status of any unresolved corrective actions.

7.6 How does the Service run the program?

A. Types of Audits. We conduct four types of audits at Service facilities to ensure environmental compliance and EMS conformance (see Table 7-2).

Table 7-2: Types of Environmental Audits
Type of Audit	Steps	Documenting and Tracking Results
Self-Environmental Compliance Audit	The Project Leader/Facility Manager: (1) Should perform a self-audit on years when the facility is not undergoing a formal or informal audit, and (2) Uses FWS Form 3-2139, Self Audit Questionnaire to inspect the facility and record findings.	The Project Leader/Facility Manager documents findings on FWS Form 3-2139 and sends it to the RECC.
Informal Environmental Compliance Audit	(1) The RECC requests that the Project Leader/Facility Manager perform an informal audit if the RECC determines, based on professional judgment of the severity and complexity of environmental issues at the station, that a site visit is not warranted. (2) The Project Leader/Facility Manager conducts a walk-through using FWS Form 3-2138, the Informal Compliance Audit form; the Federal Environmental Assessment and Management (TEAM) Guide; and the State and Service TEAM Guide Supplements. Other employees may assist the Project Leader/Facility Manager to walk through the facility and address the items on the form.	(1) The Project Leader/Facility Manager documents findings on FWS Form 3-2138 and sends it to the RECC. (2) The RECC: -Completes a report (see section 7.8) or memorandum to document the informal audit, and -Enters the results into EFCATS.
Formal Environmental Compliance Audit	(1) The RECC sends the Environmental Compliance Questionnaire, FWS Form 3-2137 or similar form to the Project Leader/Facility Manager approximately 60 days prior to the audit. (2) An auditor (usually the RECC) or audit team visits the site and researches records, interviews employees, and surveys the site for compliance. (3) The auditor/team completes the audit using the Federal TEAM Guide, State TEAM Guide Supplements, and the Service TEAM Guide Supplement (see section 7.9).	(1) Auditor/team documents findings on FWS Form 3-2134, Finding Summary Form. (2) The RECC: -Provides a written report to the audited facility to document all findings (see section 7.8), and -Enters the results into EFCATS.
Environmental Management System (EMS) Conformance Audit	(1) An auditor (usually the RECC) or audit team visits the site. (2) The auditor/team: -Reads the facility-specific Environmental Management Plan, -Searches records, and -Interviews employees to determine conformance with Executive Order 13423, Departmental and Service policies, and the facility’s Environmental Management Plan. (3) This audit provides the information necessary to correct problems and find opportunities for continual improvement.	The RECC: -Documents findings on FWS Form 3-2376, the EMS Finding Summary form, and -Enters the results into EFCATS.

B. Scheduling and Frequency of Audits.

(1) Every year, the RECCs determine the schedule for audits and provide copies of the schedule to the Environmental Compliance Branch no later than September 1. The Environmental Compliance Branch uses the schedule to allocate funding to the RECCS for conducting the audits.

(2) Frequency depends on the size and type of the facility. The Service must audit:

(a) Every facility at least every 5 years, and

(b) Facilities with an EMS every 3 years. These facilities will receive their EMS and environmental compliance audits at the same time.

(3) Some facilities, such as a stand-alone office with only two full-time employees, may not require an audit. The RECC determines this based on professional judgment of the environmental issues present at the station.

7.7 What are the types of findings from audits? Table 7-3 shows how we rank and classify audit findings.

Table 7-3: Audit Findings
These Findings…	Mean…
*A. Negative Regulatory Findings:*
(1) Significant Regulatory	· Poses, or has a high likelihood to pose, a direct and immediate threat to human health, safety, the environment, or the facility's mission. · Requires immediate attention. RECCs must immediately report significant findings to their Regional Director and the Chief, Environmental Compliance Branch.
(2) Major Regulatory	· May pose a threat to human health, safety, or the environment. · Requires action, but not necessarily immediate action.
(3) Minor Regulatory	· Usually administrative in nature, even though it might result in a notice of violation. · May also include temporary or occasional instances of noncompliance.
*B. Positive Regulatory Findings:*
· A “positive” regulatory finding means the Service is performing the regulated activity in a way that is an exemplary standard of good environmental management or the facility is demonstrating an effort to exceed requirements.
*C. Required Practices:* A required practice is an activity governed by Executive Orders or Departmental or Service policy.
(1) Positive Finding	· A “positive” finding means the Service is performing the activity in a way that is an exemplary standard of good environmental management or the facility is demonstrating an effort to exceed requirements.
(2) Negative Finding	· A “negative” finding means the facility is not performing the required activity, or is not performing it in compliance with Executive Orders or Departmental or Service policy.
*D. Management Practices:* A management practice is an activity that is not required by Executive Order or policy.
(1) Positive Finding	· A “positive” finding means going above and beyond a recommended practice.
(2) Negative Finding	· A “negative” finding means a poor management practice.

7.8 How does the Service document compliance findings after informal, formal, and EMS audits?

A. The auditor/team must write a Draft Findings Report within 30 days after completing the audit. Auditors/teams use the following sections in their reports:

(1) Section One is an executive summary that describes:

(a) The facility/site audited,

(b) The audit date,

(c) What the auditor/team audited,

(d) A list of the members of the audit team, and

(e) A summary of findings.

(2) Section Two contains background information on the site.

(3) Section Three reports environmental compliance findings. This section explains the ratings and gives recommendations for corrections.

(4) Section Four is only in reports for EMS audits. The auditors/teams explain EMS nonconformance findings and recommendations for corrections. An overall assessment of the EMS is in this section.

B. The auditor or audit team leader gives a copy of the Draft Findings Report to the Project Leader/Facility Manager.

(1) The Project Leader/Facility Manager has 60 days after receiving the report to develop corrective actions for each of the regulatory, required practice, and management practice findings and send them to the auditor/audit team leader.

(2) A reply can be as simple as "situation corrected on June 30" or "work order request submitted on May 30, 2010, for construction of cement pad." It can also be a detailed corrective action plan.

C. If the facility has received a significant regulatory finding, the auditor/audit team leader must also send a copy of the report to the Regional Director.

D. The auditor/audit team leader issues a final report within 30 days of receiving the reply on the draft report. If a reply/corrective action is not appropriate to the finding, the auditor/audit team leader contacts the facility to resolve the issue. The auditor/audit team leader sends final copies of the report to the Project Leader/Facility Manager.

E. The RECC must monitor the progress of corrective actions.

(1) The Project Leader/Facility Manager reports to the RECC 12 months after the Final Findings Report on the status of corrective actions. He/she must report to the RECC every 12 months until all corrective actions are complete.

(2) The RECC updates the status of corrective actions in EFCATS. We use this data to track the status of open deficient findings, to manage the auditing program, and to assist in developing budget requests for corrective actions.

(3) The RECCs brief higher management annually on the status of audit findings and corrections.

7.9 What is the Environmental Assessment and Management (TEAM) Guide?

A. The Chief of the Environmental Compliance Branch is responsible for ensuring the most current versions of the Federal TEAM Guide and State and Service TEAM Guide Supplements are available for Service use. To establish consistency, all of the RECCs use the TEAM Guide and its established standards when they write compliance reports.

B. The U.S. Army Corps of Engineers prepares and maintains the TEAM Guide. The guide includes protocols for compliance with applicable environmental standards that auditors and Project Leaders/Facility Managers use as a reference. The categories of protocols are:

(1) Air Emissions Management: air pollution from vehicles and equipment operated on the facility.

(2) Hazardous Materials Management: storage and handling of chemicals used at the facility.

(3) Hazardous Waste Management: generation, storage, transportation, treatment, and disposal of any type of hazardous waste on the facility.

(4) Other Environmental Issues: implementation of greening practices at the facility.

(5) Pesticide Management: use, storage, and handling of pesticides at the facility.

(6) Petroleum Oils and Lubricants (POL) Management: use, storage and handling of fuels and lubricating oils used at the facility.

(7) Solid Waste Management: collection, storage, and disposal of nonhazardous trash, rubbish, and garbage generated on the facility.

(8) Storage Tank Management: operation and maintenance of tanks (both aboveground and underground) that store hazardous materials, petroleum products, or hazardous waste.

(9) Toxic Substance Management: management of any asbestos, lead-based paint, radon, or polychlorinated biphenyls (PCBs) located at the facility.

(10) Wastewater Management: management of any wastewater that is discharged from the facility.

(11) Water Quality Management: management of drinking water systems on the facility.

(12) Environmental Management System: implementation of the facility’s EMS, if it has one.

7.10 What training opportunities are available for employees involved in the environmental compliance audit program?

A. The Chief of the Environmental Compliance Branch:

(1) Is responsible for ensuring audit training is available, and

(2) Holds quarterly conference calls with the RECCs to evaluate program objectives, discuss any ongoing concerns, and address questions.

B. Classes:

(1) The Environmental Compliance Branch conducts an environmental compliance/EMS conformance auditing class every 2 years, or more often if necessary. These courses are held at different Service field stations. Part of the class is an actual on-site environmental compliance/EMS conformance audit of the host facility. The class also includes EMS-specific training.

(2) Each trained auditor receives a certificate as a qualified auditor after successfully completing the class.

7.11 What does the Service do to ensure quality control of the program?

A. Once every 3 years, staff in the Environmental Compliance Branch accompany each RECC on at least one audit to evaluate their technical, organizational, and communication skills. Staff document these evaluations on FWS Form 3-2136, the Quality Assurance Environmental Team Evaluation Form.

B. To ensure auditors/audit teams are performing well, the RECCs request an evaluation from each facility being audited. The facility evaluates the audit using FWS Form 3-2135, the Quality Assurance Environmental Team Evaluation Facility Response, or similar form.

(1) The RECC gives the completed evaluation to the auditor/audit team lead.

(2) The RECC sends a copy to the Environmental Compliance Branch. Branch staff review the evaluation to determine if any positive or negative trends are apparent and if corrective actions are needed.

C. The Environmental Compliance Branch schedules an outside evaluator (e.g., Corps of Engineers) to accompany an audit team to at least one Service facility each year. This evaluator provides a report to the Environmental Compliance Branch and the audit team leader containing objective feedback on the Service’s audit process.

D. The Environmental Compliance Branch:

(1) Monitors EFCATS to ensure consistency and quality in report writing;

(2) Uses quality assurance/quality control (QA/QC) to measure the effectiveness of the program by reviewing replies from the Project Leaders/Facility Managers, self evaluations, and evaluations by people outside the Service; and

(3) Maintains a file of the results of the QA/QC program and evaluates it to monitor trends and determine if we need further corrective actions.

E. An important part of our QA/QC program is tracking open deficient audit findings and the accomplishment of their corrective actions. Achieving positive results from corrective actions reflects the commitment of managers to the program. Subsequent audits also reveal if repeat open deficient audit findings are occurring. Repeat deficient audit findings may be due to neglect or lack of funding.

For information on the content of this chapter, contact the Division of Engineering. For more information about this Web site, contact Krista Holloway of the Division of Policy and Directives Management.

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